Annals of Surgical Oncology Sign the Guestbook
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Tamhane, R.
Right arrow Articles by Buckingham, J. M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Tamhane, R.
Right arrow Articles by Buckingham, J. M.
Related Collections
Right arrow Prognostic factors
Annals of Surgical Oncology 9:999-1003 (2002)
© 2002 Society of Surgical Oncology

ORIGINAL ARTICLES

The Clinical Significance of Cytokeratin-Positive Cells in Lymph Nodes at the Time of Mastectomy From Patients With Ductal Carcinoma-In-Situ

Rohit Tamhane, MB, BS, Jane E. Dahlstrom, MB, BS, PhD, FRCPA, Dugald D. McCallum, BSc (Hons), MBChB, MRCP, FRCPath, FRCPA and John M. Buckingham, MB, BS, MS, FRACS, FACS

From The Canberra Hospital (RT), Canberra, ACT, Australia; ACT Pathology (JED), The Canberra Hospital and the Canberra Clinical School, University of Sydney, ACT, Australia; Capital Pathology (DDM), Canberra, ACT, Australia; and Department of Surgery (JMB), Calvary Hospital, Canberra, ACT, Australia.

Correspondence: Address correspondence and reprint requests to: John M. Buckingham, MB, BS, MS, FRACS, FACS, Calvary Clinic, Mary Potter Cct., Bruce, ACT, 2617, Australia; Fax: 61-2-6251-7440; E-mail: jm_buckingham{at}hotmail.com


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: We determined the presence or absence of and clinical significance of cytokeratin-positive cells in the lymph nodes of patients who had had mastectomies for ductal carcinoma-in-situ.

Methods: Two pathologists independently assessed the axillary lymph nodes found. All patients had either a core or open biopsy performed before the time of mastectomy. The lymph nodes were assessed with hematoxylin and eosin stain and immunohistochemistry for cytokeratin marker AE1/AE3. The slides were assessed for the presence or absence of epithelial cells. As a control, axillary lymph nodes found in prophylactic mastectomies were assessed. None of these had had a previous biopsy performed.

Results: Lymph nodes from all patients demonstrated no obvious epithelial cells on hematoxylin and eosin stain. Peripheral sinuses of lymph nodes from six patients (23%) who had mastectomies for ductal carcinoma-in-situ contained a few cytokeratin-positive cells on immunohistochemistry. The lymph nodes of the control group demonstrated no cytokeratin-positive cells. The mean follow-up of patients was 5 years, and all patients were alive without recurrence at the time of the study.

Conclusions: Epithelial cells may be present in the lymph nodes draining a site of recent breast biopsy in the absence of invasive carcinoma, indicating that these are an artifact of recent surgery and not of micrometastatic disease.

Key Words: Ductal carcinoma-in-situ • Sentinel lymph node • Immunohistochemistry • Mastectomy


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Axillary lymph node dissection has long been a part of the management of breast carcinoma. There are several disadvantages with the procedure. First, axillary lymph node dissection is associated with significant morbidity such as numbness, scarring, and lymphedema.1,2 Second, the increasing use of mammography has led to increased detection of nonpalpable breast tumors that are less likely to have axillary lymph node metastases.3 Whereas axillary lymph node dissection results in the removal of, on average, 10 lymph nodes, histological analysis is usually limited to a single histological section, which may lead to missing micrometastases (clusters of cells in the substance of the lymph node with a stromal reaction).4

Sentinel lymph node biopsy is becoming an established technique in the management of breast cancer.5–8 Sentinel lymph node biopsy has been shown to have a sensitivity of 94% and specificity of 100% in the detection of occult axillary metastases.9 On average, only one to four lymph nodes are removed during sentinel lymph node biopsy, and this allows the fewer nodes to be examined more extensively. As a result of removing fewer axillary lymph nodes, the time a patient stays in hospital is reduced, and there is less associated morbidity.

Currently, there is no uniformity in the pathologic handling of sentinel lymph nodes, although various guidelines have been published.10–12 There are ranges of protocols used, with 2 to 15 levels being examined with hematoxylin and eosin (H&E) sections. Sometimes 1 to 15 levels are examined with immunohistochemistry by using either CAM 5.2 or AE1/AE3 cytokeratin markers. In patients with invasive breast cancer, serial sections have been shown to increase the rate of detection of micrometastases11–13 in sentinel nodes. The clinical significance of micrometastases has yet to be determined in a prospective study.

There have been recent reports in which the sentinel lymph node in patients with ductal carcinoma-in-situ (DCIS) was classified as node negative with H&E stain but in which cytokeratin-positive cells were found.14,15 The sentinel lymph node status at the time of mastectomy in the management of invasive cancer is an important component in decision-making for the use of adjuvant chemotherapy. Currently, the prognostic significance of finding these cytokeratin-positive cells in the sentinel lymph node in DCIS is not known.15,16 This led us to develop a study to determine the presence or absence of and significance of cytokeratin-positive cells in the lymph nodes of patients who had had mastectomies for DCIS after prior core or excision biopsy.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
This study had Australian Capital Territory (ACT) Ethics Board approval. Patients were identified by searching two separate databases. First, patients who had had mastectomies and had a discharge diagnosis of DCIS were identified from Calvary Hospital from July 1991 to June 1998. Second, a key word search for "DCIS" was performed on the ACT pathology database from July 1994 to June 1998. For a control, a search of Calvary Hospital database was performed for patients who had had prophylactic mastectomies between June 1996 and June 2001.

The pathology reports were reviewed, and patients who had had either a 14-gauge core or open biopsy performed before the time of mastectomy and had a diagnosis of only DCIS for both the biopsy and mastectomy were included in the DCIS group. Patients with microinvasive cancer were excluded, as were those with invasive cancer of the contralateral breast. The control group comprised patients with axillary lymph nodes in prophylactic mastectomy specimens in the last 2 years who had not had a biopsy on that side.

The patients in the DCIS group were followed up by contacting the patients’ breast surgeon or general practitioner to assess whether the patient was alive and without any local recurrence or metastasis. Two pathologists independently reviewed the core biopsy, lumpectomy, and mastectomy specimens of these patients to confirm the grade and architectural type of the original diagnosis of DCIS and closely examined the tissue to exclude possible missed microinvasive cancer. In 8 of the 19 patients who had primary open biopsy, the entire specimen had been embedded for histological assessment. In the remaining cases, >70% of the tissue had been embedded. At least 12 serial sections of each core biopsy were examined. The low axillary lymph nodes from both groups had been bisected, fixed in formalin, and embedded in paraffin at the time of mastectomy. For this study, the lymph nodes were then sectioned by using the ACT Pathology sentinel lymph node protocol. The processed lymph nodes were sectioned at a thickness of 5µm, 50 µm apart, giving us 10 sections, with the deepest level being separated approximately .5 mm from the most superficial level. These 10 sections were then stained with H&E. A second 5-µm section was cut at levels 3 and 7 and stained with the cytokeratin marker AE1/AE3. These slides were then examined for the presence of epithelial cells.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
The Calvary Hospital and ACT Pathology databases identified 19 patients who had a prophylactic mastectomy over the last 2 years. Only seven patients were identified as having a prophylactic mastectomy that contained lymph nodes. These patients ranged in age from 33 to 60 years, with a median age of 46 years. The surgical specimens contained 29 lymph nodes (range, 1 to 8 lymph nodes per patient; mean, 4.1). Serial sectioning of the lymph nodes showed no epithelial cells on routine staining. No cytokeratin-positive cells were seen on immunohistochemistry examination of the nodes.

The first database identified 95 patients who had a discharge diagnosis of DCIS and had had a mastectomy. Seventy-eight of these patients were excluded because invasive cancer was present or no lymph nodes were found in the axillary tissue, and two mastectomy specimens could not be found. The second database identified 276 patients. On review of their pathology reports, only 10 had had a previous biopsy and mastectomy and had no evidence of invasive cancer. One of these patients was not included because she had invasive cancer in her contralateral breast. This left us with 26 patients who met the eligibility criteria in the DCIS group. They were all women ranging in age from 35 to 77 years, with a median age of 50 years. A total of 129 lymph nodes were examined, with a range of 1 to 14 lymph nodes per patient (mean, 4.96). In this group, 7 patients had had only a 14- gauge core biopsy, and 19 had progressed to an open biopsy. All biopsies were performed from 8 to 50 days (mean, 22.3 days) before the date of surgery. There was a mean follow-up of 5 years, with a range of 3 to 9 years. At the time of the study, all the patients were alive, without local recurrence or metastasis. All patients had been followed up with clinical examination and routine mammograms, and no patient had received any adjuvant chemotherapy or radiotherapy after the mastectomy.

On review of histology, most DCIS was high grade (20 high grade, 4 intermediate grade, and 2 low grade). Necrosis was present in 23 of the 26 cases of DCIS. Pathologically, the tumor size varied from approximately 10 to 80 mm.

Fig. 1A summarizes the location of all the DCIS tumors in the breast. Serial sectioning of the lymph nodes from the specimens with DCIS showed no epithelial cells on routine staining. All cases showed a moderate number of macrophages in the subcapsular sinus (Fig. 2A). However, on examination of the lymph nodes with immunohistochemistry, there were six cases in which cytokeratin-positive cells were found in the peripheral sinuses of at least one lymph node (Fig. 2B). These six cases also demonstrated cytokeratin-positive cytoplasmic fragments in the lymph nodes.



View larger version (12K):
[in this window]
[in a new window]
  		FIG. 1. (A) Location of ductal carcinoma-in-situ (DCIS) (total). (B) Location of DCIS (patients with cytokeratin-positive cells in lymph nodes).

 


View larger version (101K):
[in this window]
[in a new window]
  		FIG. 2. (A) Photomicrograph from a lymph node showing many macrophages (arrow) in the subcapsular sinus (stain, hematoxylin and eosin [H&E]; original magnification, x500). (B) Photomicrograph from a lymph node showing two groups of cytokeratin-positive cells (arrowhead) and many macrophages (arrow) in the subcapsular sinus (stain, AE1/AE3; original magnification, x500). (C) Photomicrograph from the primary breast carcinoma of the same patient showing high nuclear grade ductal carcinoma-in-situ (stain, hematoxylin and eosin [H&E]; original magnification, x500).

 
Of the six patients with cytokeratin-positive cells in the peripheral sinuses of the lymph nodes, one had had core biopsies only, and five had progressed to an open biopsy before the mastectomy. All patients in this group had primary high-grade DCIS with necrosis. The cytokeratin-positive cells were cytologically bland in contrast to the primary breast tumor cells (Fig. 2C). Most cases (four of six) with cytokeratin-positive cells in the lymph node had their DCIS in the upper outer quadrant. The remaining two cases had their DCIS in the upper inner and lower inner quadrants (Fig. 1B). The pathologic tumor size of the patients in this group varied from 30 to 80 mm. The biopsies in this group were performed from 13 to 50 days before the date of surgery (mean, 23.6 days). Table 1 compares the profile of patients in the DCIS group with cytokeratin-negative nodes with that of those with cytokeratin-positive nodes.


View this table:
[in this window]
[in a new window]
  		TABLE 1. Profile of patients with cytokeratin-negative lymph nodes compared with patients with cytokeratin-positive lymph nodes
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Axillary lymph nodes are assessed in invasive breast cancer for staging disease. The significance of finding occult metastases in DCIS, however, is less clear. Some studies have found that there is a small rate of metastasis in DCIS.17,18 However, a number of these cases, when reassessed, showed that either the original tumor or the distant metastases contained an invasive component.16 For this reason, the original biopsy specimens and mastectomy specimens were reassessed by the two pathologists, and the diagnosis of DCIS was confirmed.

Sentinel lymph node biopsy is changing the pathologic assessment of axillary lymph nodes for the management of breast cancer. The assessment of fewer nodes has resulted in a trend for more sections of the sentinel lymph node to be assessed.

Currently, all lymph nodes are stained with H&E for routine histological assessment. There has been recent discussion, however, on the use of immunohistochemistry for the assessment of the axillary lymph nodes.12,13 There have been recent studies published which indicate that cytokeratin cells may be present in the peripheral sinuses of axillary lymph nodes in the absence of epithelial cells being present on H&E stain.15,16,19 However, there have been no published results on the follow-up of these patients, in the medium term, to assess their clinical significance.

In gastric cancer, there has been a report that has distinguished between microinvolvement (individual cancer cells in the peripheral sinus or medulla without a surrounding stromal reaction) and micrometastasis (clusters of cells in the lymph node with a stromal reaction). Micrometastasis was found to be prognostically significant, whereas microinvolvement was significant only above a certain threshold (three or more tumor cells in >10% of lymph nodes per case).4 In invasive breast cancer, there is much debate about the clinical significance of micrometastases. Some studies have found that there is no difference in survival between patients with axillary occult metastases and those with negative nodes.20–22 However, there have been studies that have indicated that patients with occult metastases have a poorer survival than patients who are axillary node negative.23,24

We found cytokeratin-positive cells in the axillary lymph nodes in 6 of 26 patients with DCIS only. In the DCIS patients, this would indicate either a missed invasive cancer or cells in transit related to the previous biopsy. We aimed to minimize the former explanation by reviewing the original pathology and by establishing that all patients were alive and without evidence of further breast cancer at the time of the study. In general, the cytokeratin-positive cells were bland-looking epithelial cells, in contrast to the high-grade cells in the DCIS. Also, all patients in the DCIS group had a moderate number of macrophages present in the peripheral sinuses of their lymph nodes. In the control group, no macrophages were seen in the axillary lymph nodes. This leads us to believe that the cytokeratin-positive cells are a result of the previous biopsy and not a true micrometastasis.

In conclusion, we believe that cytokeratin-positive cells found in axillary lymph nodes at the time of mastectomy for DCIS are not clinically significant and should not form the basis for deciding on adjuvant chemotherapy.


   Acknowledgments
 
The authors thank Fiona Guymer, Chris Phillipa, and Jo Dennis for their technical assistance. We also thank our surgical colleagues for their assistance with this project.


   Footnotes
 
There has been a lot of debate about the significance of individual cytokeratin-positive cells in the peripheral sinuses of axillary lymph nodes. Our study found cytokeratin-positive cells in 23% of our patients with only noninvasive cancer (ductal carcinoma-in-situ) who had previous breast biopsy before mastectomy. We conclude that these cells are most likely an artifact of recent surgery and not of micrometastatic disease.

Received for publication April 29, 2002. Accepted for publication August 16, 2002.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Giuliano A, Haigh P, Brennan M, et al. Prospective observational study of sentinel lymphadenectomy without further axillary dissection in patients with sentinel node-negative breast cancer. J Clin Oncol 2000; 18: 2553–9.[Abstract/Free Full Text]
  2. Liberman L. Pathological analysis of sentinel lymph nodes in breast carcinoma. Cancer 2000; 88: 971–6.[CrossRef][Medline]
  3. Tabar L, Fagerberg G, Duffy SW, Day NE, Gad A, Grontoft O. Update of the Swedish two-county program of mammographic screening for breast cancer. Radiol Clin North Am 1992; 30: 187–210.[Medline]
  4. Siewert JR, Kestlmeier R, Busch R, et al. Benefits of D2 lymph node dissection for patients with gastric cancer and pN0 pN1 lymph node metastases. Br J Surg 1996; 83: 1144–7.[Medline]
  5. Krag D, Weaver D, Ashikaga T, et al. The sentinel node in breast cancer: a multicenter validation study. N Engl J Med 1999; 339: 941–6.
  6. Albertini J, Lyman G, Cox C, et al. Lymphatic mapping and sentinel node biopsy in the patient with breast cancer. JAMA 1996; 276: 1818–22.[Abstract]
  7. Giuliano A, Jones R, Brennan M, Statman R. Sentinel lymphadenectomy in breast cancer. J Clin Oncol 1997; 15: 2345–50.[Abstract/Free Full Text]
  8. Veronesi U, Paganelli G, Galimberti V, et al. Sentinel node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph nodes. Lancet 1997; 349: 1864–7.[CrossRef][Medline]
  9. Weaver D, Krag D, Ashikaga T, Harlow S, O’Connell M. Pathological analysis of sentinel and nonsentinel lymph nodes in breast carcinoma. Cancer 2000; 88: 1099–107.[CrossRef][Medline]
  10. Fitzgibbons PL, Connolly JL, Page DL, et al. Prognostic factors in breast cancer. College of American Pathologists Consensus statement. Arch Pathol Lab Med 2000; 124: 966–78.[Medline]
  11. Turner R, Ollila D, Stern S, et al. Optimal histopathological examination of the sentinel lymph node for breast carcinoma staging. Am J Surg Pathol 1999; 23: 263–7.[CrossRef][Medline]
  12. Van Diest P. Histopathological workup of sentinel lymph nodes: how much is enough? J Clin Pathol 1999; 52: 871–3.[Medline]
  13. Mies C, Schlesselman J. Detection of "occult" lymph node metastasis in breast cancer: should pathologists go the extra mile? Adv Anat Pathol 2000; 7: 149–52.[Medline]
  14. Pendas S, Dauway E, Guiliano R, et al. Sentinel node biopsy in ductal carcinoma in situ patients. Ann Surg Oncol 2000; 7: 15–20.[Abstract]
  15. Cox C, Ku N, Nguyen K, et al. Importance of lymphatic mapping in ductal carcinoma in situ (DCIS). Am Surg 2001; 67: 513–9.[Medline]
  16. Silverstein M, Parker S, Grotting J, Cote R, Russell C. Ductal carcinoma in situ (DCIS) of the breast: diagnostic and therapeutic controversies. J Am Coll Surg 2001; 192: 196–214.[CrossRef][Medline]
  17. Fisher B, Dignam J, Walmark N, et al. Lumpectomy and radiation therapy for the treatment of intraduct carcinoma in situ: first results of the EORTC randomized phase III trial 10852. Lancet 2000; 355: 528–33.[CrossRef][Medline]
  18. Julien J-P, Bijker N, Feintiman I, et al. Mortality among women with ductal carcinoma in situ of the breast in the population-based surveillance, epidemiology and end results program. Arch Intern Med 2000; 160: 953–8.[Abstract/Free Full Text]
  19. Kelley S, Komorowski R, Dayer A. Axillary sentinel lymph node examination in breast carcinoma. Arch Pathol Lab Med 1999; 123: 533–5.[Medline]
  20. Nasser IA, Lee AK, Bossari S, Saganich R, Heatley G, Silverman ML. Occult axillary lymph node metastases in "node-negative" breast cancer. Hum Pathol 1993; 24: 950–7.[CrossRef][Medline]
  21. Fischer E, Palekar A, Rockette H, Redmond C, Fischer B. Pathological findings from the national surgical adjuvant breast cancer project: significance of axillary nodal micro- and macrometastases. Cancer 1978; 42: 2032–8.[CrossRef][Medline]
  22. Rosen P, Saigo P, Braun D Jr. Occult axillary lymph node metastasis from breast cancers with intramammary lymphatic tumour emboli. Am J Surg Pathol 1982; 6: 639–41.[Medline]
  23. International Breast Cancer Study Group. Prognostic importance of occult axillary lymph node micrometastases from breast cancers. Lancet 1999; 354: 896–900.[CrossRef][Medline]
  24. Dowlatshahi K, Fan M, Snider H, Habib F. Lymph node micrometastases from breast carcinoma. Reviewing the dilemma. Cancer 1997; 80: 1188–97.[CrossRef][Medline]



This article has been cited by other articles:


Home page
 Ann. Surg. Oncol.Home page
K. H. Moore, K. J. Sweeney, M. E. Wilson, J. I. Goldberg, C. L. Buchanan, L. K. Tan, L. Liberman, R. R. Turner, M. D. Lagios, H. S. Cody III, et al.
Outcomes for Women With Ductal Carcinoma-in-Situ and a Positive Sentinel Node: A Multi-Institutional Audit
Ann. Surg. Oncol., October 1, 2007; 14(10): 2911 - 2917.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Surg. Oncol.Home page
H. S. Cody III
Sentinel Lymph Node Biopsy for DCIS: Are We Approaching Consensus?
Ann. Surg. Oncol., August 1, 2007; 14(8): 2179 - 2181.
[Full Text] [PDF]

Home page
 Ann. Surg. Oncol.Home page
J. C. C. Tan, D. R. McCready, A. M. Easson, and W. L. Leong
Role of Sentinel Lymph Node Biopsy in Ductal Carcinoma-in-situ Treated by Mastectomy
Ann. Surg. Oncol., February 1, 2007; 14(2): 638 - 645.
[Abstract] [Full Text] [PDF]

Home page
 J. Clin. Pathol.Home page
G Cserni, S Bianchi, V Vezzosi, H Peterse, A Sapino, R Arisio, A Reiner-Concin, P Regitnig, J-P Bellocq, C Marin, et al.
The value of cytokeratin immunohistochemistry in the evaluation of axillary sentinel lymph nodes in patients with lobular breast carcinoma
J. Clin. Pathol., May 1, 2006; 59(5): 518 - 522.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Surg. Oncol.Home page
M. El-Tamer, J. Chun, M. Gill, D. Bassi, S. Lee, H. Hibshoosh, and M. Mansukhani
Incidence and Clinical Significance of Lymph Node Metastasis Detected by Cytokeratin Immunohistochemical Staining in Ductal Carcinoma In Situ
Ann. Surg. Oncol., March 1, 2005; 12(3): 254 - 259.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Tamhane, R.
Right arrow Articles by Buckingham, J. M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Tamhane, R.
Right arrow Articles by Buckingham, J. M.
Related Collections
Right arrow Prognostic factors

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS